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Registration Form

Mandatory:

Last Name:

First Name:

E-mail address:

Address

Apt. number

City

Israeli ID or Passport

ID or Passport Number:
If passport, enter country


Cellular tel. number (including area code): Packages: 20.00 NIS per month**

** plus
Breaking – 50 agurot a message
Headline – 50 agurot a message
NonStop – 50 agurot a message

ALL PRICES DO NOT INCLUDE VAT TAX

Optional:

Home phone:
Business phone:
Fax number:
Zip Code:

Credit Card information (all mandatory)

Name as it appears on credit card:
Credit card:
Card Number (no spaces please):
Month:
Year:

If you are still uncertain, please complete the following and a sales representative will contact you at no obligation.

Convenient day and local time to call:
Contact Person:
City:
Telephone Number:
Email:
Please detail your question here:
Have a sales representative call Respond via e-mail